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Based on interview, record review, and policy review, the hospital failed to ensure that the physician responsible for the care of the patient ordered restraints prior to the application of the restraints, for one current patient (#2) of two current patients reviewed, and failed to sign restraint/seclusion orders within 24 hours for 12 out of 12 restraint/seclusion orders reviewed for one current patient (#2) on the adolescent/preadolescent unit. This failure had the potential to cause poor nursing care outcomes for all patients placed in restraints/seclusion. There were two patients placed in restraints/seclusion on the adolescent unit throughout the duration of the survey. The census on the adolescent unit was 12. The hospital census was 29.

Findings included:

1. Review of the hospital's policy titled, "Restraint," dated 10/01/18, showed:
- Restraints required the order of a physician who was responsible for the care of the patient.
- The order would be dated and timed, include the type of restraint to be used and criteria for release.
- Original orders could be renewed for a maximum of 24 hours.
- After 24 hours, before a new order could be written, a physician who was responsible for the care of the patient would see and assess the patient.

Review of the hospital's policy titled, "Medical/Professional Staff Orders - Transcription," dated 10/01/18, showed:
- Each patient's care would be directed by a physician's order.
- Written or verbal orders from the physician would be transcribed by the registered nurse (RN) or licensed practical nurse (LPN).
- A chart review would be conducted at the end of each shift and every 24 hours to ensure that all orders had been transcribed.

2. Review of the hospital's document titled, "Rules and Regulations of the Medical Staff," dated 10/01/18, showed:
- In any emergency situation, the written signed order of a physician must be obtained as soon as possible after initiation of the physical restraint or seclusion.
- Written orders must be signed by the physician within 24 hours of the initiation of the physical restraint or seclusion.
- Orders for the use of physical restraint or seclusion should not be written as a standing order or on an as needed basis (PRN).

Review of Patient #2's medical record dated 01/06/20, showed nursing progress notes that indicated the patient was placed in restraints after he hit and kicked staff, and attempts to redirect were unsuccessful. There were no physician's order to initiate physical restraint for the patient's behavior management.

Review on 01/15/20 of Patient #2's seclusion/restraint orders, showed that the physician had not signed, dated or timed 12 out of 12 telephone/verbal orders for seclusion/restraint dated from 12/11/19 to 01/07/20.

During an interview and concurrent review of Patient #2's medical record, on 01/07/20, at 12:05 PM, and 01/15/20, at 4:02 PM, Staff A, Director of Nursing (DON), stated the following:
- No physician's order was present to initiate restraint/seclusion on 01/06/20.
- The expectation was that a physician's order for restraint/seclusion would be obtained prior to initiation, except in emergency situations.
- Telephone and verbal orders for initiation of restraint/seclusion should be signed by the physician within 24 hour.



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Based on interview, record review, and policy review, the hospital failed to:
- Ensure staff notified the medical physician in a timely manner when one current patient (#2) of one current patient reviewed experienced a change in condition (A-0395).
- Ensure staff consistently followed medical physician orders to notify the provider when one current patient (#2) of one current patient reviewed experienced blood sugars above 300 (A-0395).
- Ensure staff consistently monitored, documented and notified the provider of urine ketone (when ketones are present in urine, it is a warning sign that a person's blood sugar is out of control or it can indicate the person is getting sick. High levels of ketones can poison the body) results when blood sugar readings were above 300 for one current patient (#2) of one current patient reviewed that experienced blood sugar reading above 300 (A-0395).
- Ensure staff obtained a Sliding Scale Insulin (SSI, a supplement to a patient's usual insulin dose that is long-acting used to treat uncontrolled high blood sugars) order prior to administration for one current patient (#2) of one current patient reviewed that received SSI (A-0405).
- Ensure staff administered medications according to physicians' orders and medication administration policies for four current patients (#2, #3, #30, and #31) of four current patients reviewed on the Preadolescent/Adolescent Unit (A-0405).

The hospital census was 29 and the Preadolescent/Adolescent Unit census was 12.

These failures by the hospital created an unsafe environment and had the potential to place all patients at increased risk for their health and safety.

The severity and cumulative effects of these systemic failures resulted in the hospital's overall non-compliance set forth at CFR §482.23 Condition of Participation (CoP): Nursing Services. As a result of the survey, the CoP: Nursing Services was found to be out of compliance.

Based on interview, record review, and policy review, the hospital failed to:
- Ensure staff notified the medical physician in a timely manner when one current patient (#2) of one current patient reviewed experienced a change in condition.
- Ensure staff consistently followed physician orders to notify the provider when one current patient (#2) of one current patient reviewed experienced blood sugar readings above 300.
- Ensure staff consistently monitored, documented and notified the provider of urine ketones (when a type of sugar is present in the urine, may indicate high blood sugar levels in the body) results when blood sugar readings were above 300 for one current patient (#2) of one current patient reviewed that experienced blood sugar readings above 300.
These failures had the potential to result in patient deterioration or death, when patient results that were outside of normal, were not reported the provider, and could affect all patients. The hospital census was 29.

Findings included:

Review of the hospital's policy titled, "Recognition and Reporting Changes In A Patient Condition," dated 10/01/18 showed:
- All patients will be assessed for changes in medical stability at least each shift, and as believed appropriate by the nurse.
- Mental Health Technicians (MHT) and other staff with patient contact shall report any changes in medical stability to the nurse immediately.
- The nurse must address the change in status immediately.
- The staff nurse must notify the charge nurse of change in patient condition.
- Changes in medical condition shall include, but are not limited to changes in level of consciousness or alertness.
- The nurse shall assess all reports of changes in condition immediately, and review as appropriate with the nursing supervisor, attending physician, or the covering on-call physician.

Review of Patient #2's medical chart showed that he was 13-years-old and was diagnosed with Type I Diabetes (disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin [hormone] to control) at the age of 10. The patient's blood sugars were uncontrolled and his readings ranged between lows in the 40's to HI (glucometer machine registered sugars up to 600, so a HI reading was over 600). Normal adolescent (age 13 to 19) blood sugars range between 90 and 130.

Review of the patient's Physician's Orders showed that:
- On 12/10/19 at 10:00 AM, an order was written that directed staff to test the patient's urine for ketones when his blood sugar reading was above 300, and to notify the physician with blood sugar readings above 300.
- On 12/11/19 at 5:15 PM, staff were directed to follow the hospital's hypoglycemic (low blood sugar) protocol for sliding scale insulin (SSI, refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood sugar ranges) that directed staff that if the patient's blood glucose (sugar) level is less than 70, give six ounces of juice or one tube of 15 grams (g, unit of measurement) of glucose gel. Recheck the patient's blood glucose in 15 to 20 minutes and repeat treatment until blood glucose is greater than 100, and contact the physician if the patient's condition persists.
- On 12/24/19 at 7:50 PM, an order was written that directed staff to administer Humalog (rapid acting) Insulin 10 Units (U, measurement of medication) times one now, recheck the blood sugar in one hour and notify the provider of results.
- On 12/24/19 at 9:00 PM, an order was written that directed staff to administer Humalog Insulin 5U and recheck the patient's blood sugar in one hour and notify the provider of results.
- On 12/24/19 at 10:00 PM, an order was written that directed staff to administer Humalog Insulin 5U and recheck the patient's blood sugar in one hour. If the patient's blood sugar is still coming down, check blood sugars every two hours until morning and then resume normal blood sugar check routine.

Review of the Physician's Order sheet dated 12/24/19 showed that the last written physician order received by staff was at 10:00 PM.

Review of the patient's Diabetic/Insulin Record showed that:
- On 12/24/19 at 7:50 PM, the patient's blood sugar reading was "HI" and the patient received 10U of insulin.
- On 12/24/19 at 9:00 PM, the patient's blood sugar reading was "HI" and the patient received 5U of insulin.
- On 12/24/19 at 10:00 PM, the patient's blood sugar reading was 474 and the patient received 5U of insulin.
- On 12/24/19 at 11:00 PM, the patient's blood sugar reading was 123.
- On 12/25/19 at 1:00 AM, the patient's blood sugar reading was 73, the patient was unable to swallow food, so Glutose 15g was administered.
- On 12/25/19 at 3:05 AM, the patient's blood sugar was 50 and Glutose 15g was administered.
- On 12/25/19 at 3:20 AM, the patient's blood sugar was 62 and Glutose 15g was administered.
- On 12/25/19 at 3:25 AM, the patient was given peanut butter, graham crackers and milk.
- On 12/25/19 at 3:50 AM, the patient's blood sugar was 92.
- On 12/25/19 at 5:00 AM, the patient's blood sugar was 177.

Review of the patient's Progress Record showed that:
- On 12/24/19 at 7:50 PM, Staff FF, Registered Nurse (RN), documented that the patient's blood sugar registered "HI" on the glucometer. Staff Z, RN, Family Nurse Practitioner Certified (FNP C), was notified of the "HI" reading and orders were received and followed. At 9:00 PM the patient's blood sugar registered "HI" and insulin orders were received and followed. At 10:00 PM the patient was alert, able to talk and his blood sugar reading registered 474. At 11:00 PM the patient rested in bed with his eyes closed and his blood sugar reading registered 123.
- On 12/25/19 at 1:00 AM, Staff NN, RN, documented that the patient was difficult to arouse but he responded to touch. The patient's blood sugar reading registered at 73 and Glutose 15g was administered.
- On 12/25/19 at 3:05 AM, Staff NN, RN, documented that the patient responded to tactile stimuli (sense of touching) and turned away from staff. The patient refused to eat peanut butter, graham crackers or milk, so Glutose 15g was administered (the patient's blood sugar reading was 50 at that time).
- On 12/25/19 at 3:25 AM, Staff NN, RN, documented that the patient was more alert and he agreed to eat peanut butter, graham crackers and milk after he had consumed Glutose 15g (the patient's blood sugar reading was 62 at that time).
- On 12/25/19 at 3:50 AM, Staff NN, RN, documented that the patient's blood sugar reading was 92.
- On 12/25/19 at 5:00 PM, Staff NN, RN, documented that the patient's blood sugar reading was 177.

Staff failed to:
- Follow the hospital's Hypoglycemic Protocol for Sliding Scale Insulin when staff failed to recheck the patient's blood sugar within 15 to 20 minutes after staff administered 15g of Glutose, repeat treatment until the patient's blood sugar was greater than 100 and contact the physician when the patient's blood sugar remained under 100 from 1:00 AM until 5:00 AM (a total of four hours).
- Notify the physician when the patient had a change in status. At 1:00 AM, when the patient was difficult to arouse, staff did not document that they reassessed the patient until 3:05 AM (two hours). When staff assessed the patient at 3:05 AM, he responded to tactile stimulus and his blood sugar reading was 50.
- Reassess the patient in a timely manner when he experienced a change in status at 1:00 AM, notify the physician when the patient's blood sugar did not come up to 100 after several administrations of Glutose 15g and when the patient was difficult to arouse and responded to tactile stimulus at 3:05 AM.

2. During an interview on 01/14/20 at 10:36 PM, Staff A, RN, Director of Nursing (DON) stated that:
- Staff did not follow the hospital's hypoglycemic protocol when staff failed to repeat the treatment until the patient's blood sugar reading was above 100.
- She expected staff to use their nursing judgement and reassess the patient prior to two hours passing, when the patient was difficult to arouse.
- Staff probably should have notified the physician with any changes in the patient's condition on 12/25/19.

During an interview on 01/14/20 at 3:11 PM, Staff Z, RN, Family Nurse Practitioner Certification (FNP C), stated that:
- Staff reported that the patient had received the Christmas Eve meal and that his carbohydrate intake was off due to the special meal consumed by the patient.
- Staff were informed to send the patient out (to a near-by Emergency Department) if his blood sugar reading continued to read "HI" on the glucometer.
- Based on the patient's SSI orders and with collaboration with Staff DD, Physician, was how she based the order to administer SSI.
- The last time she heard from staff was at 11:00 PM.
- She expected staff to notify the provider on-call with the patient's change in condition and low blood sugar readings of 50 and 62.
- She expected staff to check on the patient before two hours had passed, after the patient was difficult to arouse with a blood sugar of 73.

During an interview on 01/14/20 at 10:06 PM, Staff NN, RN, stated that:
- On 12/25/19 at 1:00 AM, the patient was not able to swallow when staff offered peanut butter, graham crackers and milk for a blood sugar of 73, and the patient was difficult to arouse.
- The patient's blood sugar reading at 1:00 AM was 73, but based on the patient's presentation of being difficult to arouse, she administered Glutose 15g.
- The patient experienced difficulty swallowing the Glutose and some of the Glutose "bubbled" out of his mouth.
- She requested for Staff PP, MHT, to sit with the patient because the patient was not acting as he had with previous nights she had cared for him.
- At 3:05 AM, she tickled the patient and performed a mild sternal rub (knuckles of a closed fist are rub over the center of the chest of a person who is not alert and does not respond to verbal commands) to elicit a response from the patient.
- She did not notify the physician when the patient presented with a change in status, was difficult to arouse, had difficulty swallowing and was "different" from previous times she had cared for him.
- She did not follow the hospital's Hypoglycemic Protocol.
- She had concerns about the patient until he began to consume the peanut butter, graham crackers, and milk at 3:25 AM (almost two and a half hours after the patient was difficult to arouse).

During an interview on 01/14/20 at 10:56 PM, Staff PP, MHT, stated that Staff NN, RN, asked him to sit with the patient on 12/25/19 around 1:15 AM, because the patient was unresponsive when she attempted to administer Glutose to him, and she wanted to make sure the patient did not spit out the medication. When he verbally called out the patient's name for approximately two minutes, the patient did not verbally respond, but half way opened one eye, and was hard to arouse during vital sign checks.

During an interview on 01/15/20 at 12:00 PM, Staff DD, Physician, stated that:
- On 12/24/19, Staff Z, RN, FNP C, contacted him about the patient's "HI" blood sugar readings and they discussed if the patient needed to be sent out.
- If the patient did not respond to SSI intervention, then the patient would have been sent to a near-by Emergency Department for evaluation.
- It was appropriate for Staff NN, RN, to administer Glutose 15g based on the presentation of the patient being difficult to arouse and not his blood sugar reading of 73. The patient's documented behaviors of being difficult to arouse at 1:00 AM could be a result of the patient's blood sugar coming down.
- It would have been good if the nurse notified him when the patient was difficult to arouse and his blood sugar read 73 at 1:00 AM.
- He expected staff to assess the patient before two hours had passed, when the patient first experienced a change in condition at 1:00 AM.
- The nurse should have notified him when the patient's blood sugar readings did not reach above 100 until 5:00 AM.
- The nurse did not follow the hospital's hypoglycemia protocol when he was not notified of the change in the patient's condition at 1:00 AM, when the patient's blood sugars did not reach above 100 for four hours and when he was not notified when the patient's blood sugar remained under 100 after several administrations of Glutose had been given.

3. Review of the hospital's policy titled, "Medical/Professional Staff Orders - Transcription," dated 10/2018, showed that each patient's care will be directed by a physician's order.

Review of the patient's Diabetic/Insulin Report dated from 12/10/19 to 01/14/20, showed staff documented the patient's urine ketones when his blood sugar was above 300, 34 out of 73 opportunities.

Review of the patient's Diabetic/Insulin Report, Physician's Orders and Progress Notes dated from 12/10/19 to 01/14/20, showed staff documented that the physician was notified when the patient's blood sugar was above 300 for seven out of 73 opportunities.

During an interview on 01/14/20 at 10:36 AM, Staff A, RN, DON, stated that she had noticed that staff did not consistently document notification to the physician when the patient's blood sugar was above 300, as it was directed by physician's orders. Staff also did not document 100% of the time the patient's urine ketone results when his blood sugar was above 300, as directed by physician's orders.

Based on interview, record review, and policy review, the hospital failed to ensure staff administered medications according to physicians' orders, and medication administration policies, for four current patients (#2, #3, #30, and #31) of four current patients reviewed, and one discharged patient (#21) of one discharged patient reviewed on the adolescent/preadolescent unit. The hospital also failed to ensure that staff obtained a physician's order prior to the administration of sliding scale insulin (SSI, refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood sugar ranges) for one current patient (#2) of one current patient reviewed who received SSI. These failed practices had the potential to cause harm and/or ineffective medication therapy to patients admitted to the hospital. The adolescent/preadolescent unit census was 12. The hospital census was 29.

Findings included:

1. Review of the hospital's policy titled, "Medical/Professional Staff Orders Transcription," dated 10/01/18, showed that each patient's care would be directed by a physician's order, and that physicians' orders were supported by documented rationale for all medications, medication changes, restraint/seclusion and precautions.

Review of Patient #2's Physician's Orders dated 12/10/19, showed no order had been written for the patient to receive a one time order for Humulin Regular Insulin (short acting insulin [medication that regulates the amount of sugar in the blood]) 24 Units (U, measurement of medication).

Review of the patient's Scheduled Medication Administration Record (MAR) dated 12/10/19, showed Staff LL, RN, documented that she administered 24U of Humulin Regular Insulin at 9:45 AM to the patient.

During an interview on 01/14/20 at 10:36 AM and at 10:45 AM, Staff A, RN, Director of Nursing (DON) stated that:
- She did not find an order dated 12/10/19, to administer 24U of Humulin Regular Insulin to the patient.
- The hospital did not follow or have a "high insulin" protocol because that protocol was too confusing for staff to follow.
- Staff were expected to follow the SSI parameters ordered by the physician based on the patient's individual insulin needs.

During a telephone interview on 01/15/20 at 10:11 AM, Staff LL, RN, stated that:
- Patient #2 was a new admit to the unit and his blood sugar reading was over 300, but the hospital did not receive any insulin orders at the time of his admission (the patient was admitted to the hospital on 12/09/19 at 11:22 PM, from a near-by Emergency Department).
- She did not notify the physician of the patient's elevated blood sugar.
- After she received report, she reviewed the patient's medical record, but was not able to find any orders for insulin and/or protocols to follow.
- When she contacted Staff DD, Physician, because she did not have any insulin ordered, he instructed her to follow the hospital's "high insulin protocol" (Staff A, RN, DON, stated that the hospital did not have a "high insulin" protocol and staff were expected to follow SSI parameters ordered by the physician).
- The patient had missed his morning dose of insulin because no insulin orders had been included, so when she calculated the SSI dose to be administered, it was based on the patient's regular insulin dose and she calculated a dose of 24U.
- She confirmed her calculated dose of 24U with Staff DD, Medical Physician, before she administered the dose to the patient.
- Based on her calculation, she administered 24U of Humulin Regular Insulin to the patient on 12/10/19 at 9:45 AM.
- She believed she wrote a telephone order for the onetime dose on the Physician's Order sheet (no telephone order was found).

During an interview on 01/15/20 at 12:00 PM, Staff DD, Physician, stated that:
- He did not recall Staff LL, RN, calling him on 12/10/19 for the patient's elevated blood sugar, and he did not recall giving Staff LL, RN, a one time order for 24U of Humulin Regular Insulin.
- An order for 24U of Humulin Regular Insulin was not a dose that he would normally order for a onetime dose.
- 24U would be included with an adjustment to the patient's normal insulin dose, and 24U was a high dose.
- With the patient being a new admission and unfamiliar to him and staff, he typically ordered between five and 10U of Humulin Regular Insulin for additional coverage, and not 24U, without knowing how the patient would respond to a high dose.

Review of Physician's Orders showed that Staff DD, Medical Physician, ordered SSI consistently between five and 10 Units, and no SSI order was written over 10 Units from 12/10/19 to 01/08/20 for the patient.

This failed practice by the hospital to ensure SSI was only administered per physician's orders placed all patients that required SSI at increased risk for their health and safety.

2. Review of the hospital's policy titled, "Medication Administration," dated 10/01/18, showed the following:
- RNs and licensed practical nurses (LPNs) were qualified to administer medications on the inpatient units.
- Nurses should administer medications in accordance with established standards of nursing practice.
- Nurses were to document the time and initial the medication administration record (MAR) as each patient's routine (scheduled) and as needed (PRN) medications were administered.
- One step in the procedure for licensed nurses to prepare medications for administration, was to verify the right medication.
- Medication refusals by patients, and medications held by nursing staff, were to be documented in the nursing progress notes, and the physician was to be notified.
- Each dose of medication that was held, nursing staff were to write "hold" in the space that corresponded to each dose of the held medication, and document the explanation on the back of the MAR.
- Discontinued medication orders were to be written as "DC'd" on the MAR by nursing staff, followed by his/her initials, date and time on the front of the MAR, and the medication was to be blocked out by yellow highlighter.

2. Review of the hospital's policy titled, "Medication Administration Times," dated 10/01/18, showed unless otherwise specified by the prescribing provider, twice daily (BID, medical term that means two times a day) administration of regularly scheduled medications for the adolescent unit occurred at 8:30 AM and 4:30 PM.

Review of hospital policy titled, "Medical/Professional Staff Orders Transcription," dated 10/01/18, showed that nursing staff would transcribe written or verbal physicians' orders, and that chart reviews would be conducted at the end of every shift and every 24 hours for accuracy.

Although requested, the hospital failed to provide a policy and procedure that addressed medication refusals for adolescents/preadolescents with a legal guardian.

Review of Patient #3's Nursing Progress Records dated 01/03/20 at 10:15 PM, and 01/04/20 at 6:30 AM, showed:
- Medications were not started because the pharmacy was closed;
- Missed medications included Melatonin (a hormone used to treat sleep disorders); and
- The patient did not go to sleep and stayed awake all night.

Review of Patient #3's Scheduled MAR dated 01/05/20 through 01/09/20, and one undated handwritten MAR showed:
- No dates for nine medications that were administered by nursing staff;
- No initialed administration or documented refusal/hold for Clonidine (a medication used to treat attention deficit hyperactivity disorder [ADHD]), Strattera (a medication that affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control), Lithium (a medication primarily used mental health disorders, reduces the risk of suicide), Latuda (an antipsychotic medication used to treat certain mental/mood disorders), Melatonin (a hormone used to treat sleep disorders), and Mighty Shakes (a liquid dietary supplement that adds calories and protein);
- No physician's order to change the 8:30 AM and 4:30 PM (BID) medication administration times for Strattera, Clonidine, and Lithium administered at 10:30 AM and 8:30 PM, and Mighty Shakes administered at 12:00 PM, 2:00 PM, 3:00 PM, 7:55 PM, and 8:30 PM; and
- No notification of the physician or the patient's legal guardian that the preadolescent patient refused one dose of Latuda.

Review of Patient #31's Scheduled MAR dated 01/10/20 through 01/15/20, showed no notification of the physician or the patient's legal guardian, that the preadolescent patient refused one dose of Miralax (a laxative used to treat constipation) on 01/12/20, and one dose on 01/14/20, when the patient had a documented diagnosis of chronic constipation.

During an interview on 01/14/20 at 2:30 PM, with concurrent record review of Patient #31's Scheduled MAR, Staff CC, Pharmacist, stated he was unsure of the hospital policy for adolescents/preadolescents who refused medications.

Review of Patient #2's Scheduled MAR showed no initialed administration or documented refusal/hold by nursing staff for 14 medication doses 01/13/20 through 01/15/20.

Review of Patient #30's undated handwritten Scheduled MAR, showed no dates for three medications administered by nursing staff.

During an interview on 01/14/20 at 2:30 PM with concurrent record review of Patient #30's undated handwritten MAR, Staff CC, Pharmacist, confirmed there were no dates of medication administration by nursing staff.

Review of hospital documents titled, "Medication Discrepancy Reports," dated November and December 2019, showed the following:
- The November report showed 12 medication discrepancy (medication errors) incidents.
- Review of each incident related to the 12 discrepancies revealed a total of 42 missed medication doses, four incidents of wrong medications administered, 2 incidents of the patient's home medication list not reconciled, one transcription error, one medication administration without an order, and one incident of the wrong dose administered, for a total of 51 errors.
- On 11/07/19, Patient #21 received the wrong medication for three days.
- The wrong medication was placed on the MAR for Patient #21, and 24-hour chart checks conducted by nursing staff failed to catch the error.
- The December report showed nine medication discrepancy incidents.
- Review of each incident related to the nine discrepancies revealed a total of six missed medication doses, two incidents of administration without documentation on the MAR, two transcription errors, one incident of the wrong dose administered, one medication administration without an order, and one medication administered too soon, for a total of 13 errors.
- The majority of medication errors were related to nursing staff.

During an interview on 01/06/20 at 4:50 PM, Staff A, DON, stated the onsite pharmacy was open Monday through Friday from 8:00 AM to 5:00 PM. After hours, medication orders were sent to the telepharmacy (off-site pharmacy), where orders were then entered and processed.

During an interview on 01/14/20 at 2:30 PM, Staff CC, Pharmacist, stated that incident reports and medication variance reports were handled by the Risk Manager until her recent retirement and they were now handled by Staff J, House Supervisor. He stated that any reports that involved medication errors related to the pharmacy would be sent to him to analyze why the incident occurred. He stated the biggest area of errors that were identified was that new orders were not sent to the pharmacy to be reviewed and processed. He stated medication errors were reported to the Risk Manager, then he reported any errors he discovered to the Risk Manager as well. He stated some medication discrepancies were taken to the Risk Manager that he was unaware of, which concerned him. He stated he was unsure if all medication errors were reported on the monthly discrepancy reports, as not all medication errors were reported to the pharmacist. He stated the onsite pharmacy was open Monday through Friday from 7:30 AM to 4:00 PM and after hours order entry occurred until 9:00 PM at the telepharmacy, and that orders after 9:00 PM waited for review and processing until he arrived to the pharmacy the next morning.

During an interview on 01/15/20 at 4:02 PM, Staff A, DON, stated:
- The expectation for medication missed dosages, documentation, and notifications, was that if the error was discovered outside the one-hour window of administration, nursing staff were to notify the physician and complete a medication variance report.
- The process to report medication errors was to complete a medication variance report, notify the physician, and send the report to the House Supervisor.
- The process to report medication errors that were discovered through chart audit was to notify the physician, complete a medication variance report, and send the report to the Risk Manager.
- Nursing staff were expected to contact the physician for an order to change medication times.
- Audits that were conducted on a routine basis included nursing documentation, chart reviews, chart audits, and medication variance reports for trends and education of staff.

During an interview on 01/08/20 at 11:08 AM, Staff N, Vice President of Clinical Operations, stated the hospital had terminated their contract with the telepharmacy they had used for after-hours services effective 01/01/20, due to too many errors. Staff N stated the hospital did not collect data on medication errors to track and determine trends.

The hospital failed to track and analyze data for trends for all medication errors that could have a negative impact on patients' health, safety, and overall treatment.




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